Effect of inhaled hypertonic saline on hospital admission rate in children with viral bronchiolitis: a randomized trial

Abstract

Objective: We sought to determine whether inhaled 3% hypertonic saline (HS) reduces admission to hospital in ambulatory children with moderately severe viral bronchiolitis. Secondary objectives compared changes in respiratory scores before and after treatment and assessed the need for unscheduled medical intervention within 7 days. Methods: Children under the age of 2 years presenting with moderately severe viral bronchiolitis to the emergency department of 4 general hospitals from November 2008 to March 2009 were randomly assigned to receive 3 consecutive 4-mL doses of nebulized 3% HS (treatment group) or 0.9% normal saline (NS; control group) in a double blind fashion, each coadministered with 1 mg salbutamol. Outcome measures included the difference in hospital admission rate and changes in respiratory distress scores. Results: A total of 81 children (mean age 8.9 mo, range 0.7–22 mo) were assessed over 88 visits on an intention-to-treat basis. No statistically significant differences were found between treatment groups. Children in the HS group had a nonsignificant trend toward greater improvement compared with NS controls with a same-day admission rate of 18% (95% confidence interval [CI] 9%–32%) versus 27% (95% CI 16%–42%), respectively. Respiratory Assessment Change Scores (RACS) favoured the HS group over NS controls (mean RACS 4.7 [95% CI 3.6–5.8] v. 3.7 [95% CI 2.5–4.9], respectively), although the CIs overlap and these differences were not statistically significant. Conclusion: The short-term use of nebulized 3% HS did not result in any statistically significant benefits, although a nonsignificant trend toward a decrease in admission rate and improvement in respiratory distress was found. A larger study would be required to determine whether these trends arise from a clinically relevant treatment effect.

Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature

“…1 In conclusion, we agree with the AAP guidelines 1 regarding the use of nebulized hypertonic saline to reduce bronchiolitis scores and LOS for infants with bronchiolitis who are expected to be hospitalized for more than 72 hours. We also note that recent trials [21][22][23][24][25][26][27][28][29][30][31] suggest that hypertonic saline reduces admission rates from the ED, and we believe there may be a role for hypertonic saline in this setting. Given the safety of this therapy and the lack of other effective therapies for these patients, use of hypertonic saline should be attempted in multiple doses in all patient care settings where nebulization can be administered.…”

“…Since Zhang's systematic review, 2 additional trials in the ED, with admission rates as a primary outcome, have been published. 27,31 A larger study by Wu et al 31 supported a reduction in hospital admissions of about 50%. Although this reached statistical significance, the number of patients enrolled did not meet the power criteria.…”

“…Also in 2010, Kuzik et al 27 conducted a prospective, randomized trial to determine the efficacy and safety of an intensive 3% hypertonic saline and albuterol vs NS and albuterol regimen in children with viral bronchiolitis. The primary outcome was hospital admission rate according to the attending physician.…”

7% Hypertonic Saline in Acute Bronchiolitis: A Randomized Controlled Trial

“…7 Since this review, additional studies have evaluated HS in infants with bronchiolitis: 1 in an ambulatory setting, 3 in an emergency department (ED), and 5 in hospitalized patients. 6,[8][9][10][11][12][13][14][15][16] All of these studies have shown a reduction in pulmonary severity scores and/or a trend toward reduced admission rates in the HS group. Of note, all investigations to date have shown HS to be safe, with no patients experiencing decreased oxygen saturation, apnea, or cyanosis after administration of the medication.…”

“…[8][9][10]15,16,21 However, HS appears to be safe when used alone to treat infants with bronchiolitis. 11,12,22 Another limitation is that the modified BSS is not widely used and has not been externally validated. 8 However, it has been an established respiratory assessment tool in our institution for more than 7 years and incorporates all the major criteria used by other scoring systems for bronchiolitis, including oxygen saturation.…”